Renal transplantation

by Anna Savchuk

Renal transplantation is the preferred treatment for patients with end-stage renal disease. It offers better quality of life and confers greater longevity than long-term dialysis.

Diabetic nephropathy accounts for 40% of the diseases resulting in renal transplantation. This subgroup of pts are also more prone to complications after renal transplantation. The spectrum of diseases in transplant pts is different from the general population. The classical presentation of common medical disorders may be modified by immunosuppressive medication.

Transplant coordinators should be called early for any pt who may meet brain death criteria in the new future.Absolute C/Is for organ donation include HIV, sepsis, non-CNS malignancy and severe CVS disease.Age is also a relative C/I (i.e. organs not harvested from pts >75 years of age).The pretransplantation workup of a potential donor includes testing for CMV, HSV, EBV, HIV, Hep A, B, C, D + E and HTLV type 1.

The Transplantation Process

Following brain death, a number of physiological changes occur that need to be rectified if donor organ perfusion is to be preserved.Increased cerebral oedema after trauma or stroke results in catecholamine release and HT.With brainstem necrosis, catecholamine levels drop rapidly resulting in hypotension. This should be corrected with fluid and vasopressors

About 75% of organ donors develop diabetes insipidus due to pituitary necrosis and this leads to hypovolaemia.Systemic thermal control is often lost due to hypothalamic ischaemia which results in coagulopathy, hepatic dysfunction and cardiac dysfuction.

Allograft : graft between genetically dissimilar individuals of the same species.Autograft : graft in which donor and recipient are the same individual.Xenograft : Donor and recipient belong to different species.

Donors

Wet ischaemia time (time from cessation of circulation to removal of organ and its placement in cold storage) should not exceed 30 mins.Transplanted kidney is placed in the R or L lower quadrant of the abdomen in an extraperitoneal position. On examination, the transplant is easily palpable.

The transplant renal a is anastomosed to the ipsilateral internal or external iliac arteria, the renal vena to internal or external iliac vena and the transplant ureter to the bladder.

Generally a single kidney is transplanted.Acute rejection appears within the first 3 posttransplant months and affects 30% of cadaveric transplants and 27% of transplants from living donors. Approximately 20% of patients with transplants experience recurrent rejection episodes. Patients present with decreasing urine output, hypertension, rising creatinine, and mild leukocytosis. Fever, graft swelling, pain, and tenderness may be observed with severe rejection episodes. The final diagnosis depends upon a graft biopsy.

The end…